Moving beyond the challenges of interoperability, Information
Governance and engagement: Quality improvement enabled by the
South-West EPaCCS
Dr Julian Abel
Consultant in Palliative Care Weston Super Mare
Has medicine lost its way?
• Most sensitive predictor of hip fracture is to ask the question are you at risk of falls – 40% predictive
• Bone densitometry 30% predictive value
• Spend on long-term conditions in 1960s was in region of 10%, now 75% of £1 billion budget
• Much of therapeutics is unscientific and unreliable – Bad Pharma plus others
Primary Care
• Driven to distraction by fulfilling service demands that are of variable efficacy and quality
• Difficult to see or even do the things that are most effective
• No time for advance care planning
EPaCCS
• Lack of engagement in use of EPaCCS is a marker of where primary care finds itself.
• The technological problems are the least of the issues, the main issue being engaging in advance care planning
• Getting this information on to EPaCCS is a minor work around whilst there is no interoperability
• Governance issues are blown out of all proportion – poor track record of NHS IT eg care.data
Use of advance care planning and EPaCCS is a no brainer
2
Probability of on-time successful completion at each step
Steps 90.00% 99.00% 99.90% 99.99% 99.999% 1 90.00% 99.00% 99.90% 99.99% 99.999% 2 81.00% 98.01% 99.80% 99.98% 99.998% 4 65.61% 96.06% 99.60% 99.96% 99.996% 8 43.05% 92.27% 99.20% 99.92% 99.992% 16 18.53% 85.15% 98.41% 99.84% 99.984% 32 3.43% 72.50% 96.85% 99.68% 99.968% 64 0.12% 52.56% 93.80% 99.36% 99.936% 128 0.00% 27.63% 87.98% 98.73% 99.872%
How does the complexity of your process affect reliability?
If the reliability of each step is 90% then
the overall reliability for the 4 steps
together is only 65.61% (.90^4=.6561)
Aim: Patients identified as needing ACP, and this is completed and placed
on EPaCCS
Complexsystemsareeasilyveryunreliableweneedtobebe erthat95%accurateateachstep
Iden fica onofpeopleatendoflife
Needforadvancecareplanningcommunicated
Advancecareplanningcompleted
ACPavailableonEPaCCS
Langley,G.J.,Nolan,K.M.,Nolan,T.W,Norman,C.L.,&Provost,L.P.(2009).Theimprovementguide:Aprac calapproachtoenhancingorganiza onalperformance(2ndEd.).SanFrancisco:Jossey-Bass.
A erthebaselineauditaskthreeques ons
Addressthecomplexityinastructuredway
ThelensthroughwhichanImproverlooksataproblem
• h p://www.youtube.com/watch?v=xKv--YA8XJE&feature=related
TheSystem
Varia on
Theoriesofwhy/what
HumanBehaviour
PDSATesting:thesequenceofPDSAs
A P
S D
APS
D
A P
S DD S
P A
DATA
FEEDBACK TO
FRONTLIN
E
STAFF:
Complia
nce
with
form
comple
tion
D SP A
Cycle 1A:
Cycle 1B:
Cycle 1D:
Cycle 1C:
Cycle 1E:
Process Change PDSA: Testing incorporation of form for getting medicines right into prescriptions chart
Recognising patients are risk of fall
20
30
40
50
60
6/12 7/12 8/11 9/10 10/10 11/9
Min
ute
s
Huddles tried Nurses report
restructured
Permission to
update board
As a result
of a near miss
Flag on board
Goal
Datatoshowwhatwearedoing
Run chart for MAU
0
2
4
6
8
10
12
13/04/2015 14/04/2015 15/04/2015 21/04/2015 22/04/2015 23/04/2015 24/04/2015
Pts suitable for TEP
Pts with a TEP
Meeting with team.
A model for improvement within GP practices for end of life care.
1. CCG decision to run improvement project in GP surgeries around ACP/EPaCCS
2. Team gathered together to lead project
3. Meeting held at willing surgery to start driver diagram, generate theories and start PDSA testing
Initial phase
1. how to identify patients
2. identify who is the most appropriate person to do the advance care planning
3. set a date for completion of ACP
4. Ensure that systems are in place so that the outcome of the ACP is placed on the EPaCCS
Next steps
• Follow up meetings every 2 to 4 weeks of 20 minutes
• PDSA cycle testing with looking at number of people added to EPaCCS
• Outcome, process and balancing measures
• Overall aim is to ensure that all patients who should have the opportunity to do ACP, actually do so.
Long term outcome measures
• Percentage of patients who have completed ACP by diagnosis
• Difference in place of death for patients who have completed ACP according to diagnosis
• Hospital usage of people who have done ACP compared to those who have not, including length of stay, number of days in hospital in the last year of life, number of emergency admissions and cost of hospital care in the last year.
• Total impact on hospital admissions • Demonstration of how the process of quality improvement
methodology results in consistent improvement with long term benefits.
Recommendations
1. Building infrastructure for quality improvement in end of life care with partnerships with the Academic Health Science Networks (AHSNs). They will be launching patient safety collaboratives in mid 2015 which will provide a local resource for health professionals in use of quality improvement methodology. Programmes of education for professionals and leaders in end of life care should be offered.
2. Formation of a programme with NHS IQ to build on the experience of EPaCCS. This should include national/ regional leads for a rolling out a programme of use of quality improvement methodology combined with EPaCCS. Ideally, clinicians experienced in end of life care and quality improvement should fill this role.
3. The National End of Life Care Intelligence Network to continue its programme of providing end of life reports that can be used at locality level to support use quality improvement methodology. This should include regular, prospective, custom made reporting as well as long term outcome reports on impact. This programme will build on combining data sets, including ONS, HES, EPaCCS and costing.
4. The National End of Life Care Intelligence Network to act as a central repository for national EPaCCS data. Production of national, regional and local reports will help end of life groups to understand what is working and what is not, where effort needs to be put and look at areas of good practice. It will also support Clinical Commissioning Groups in commissioning intentions.
5. Use of data to provide evidence on impact for NHS England in setting priorities for commissioning as part of the annual NHS plan. This should include use of improvement methodology to address the issues of advance care planning and the use of EPaCCS in all health care settings, whether this is in the community or secondary care.
